Andreas B. Imhoff

Purpose: To conduct a Delphi expert consensus on the biomechanics, indications and contraindications, surgical techniques, and complications associated with augmenting anterior cruciate ligament (ACL) reconstruction (ACLR) with either anterolateral ligament reconstruction (ALLR) or lateral extra‐articular procedure (LEAP). Methods: Forty panel members were included. In Round 1, the panel addressed 18 open‐ended questions on ALLR or LEAP in ACL surgery, followed by 8 semi‐open‐ended questions in Round 2. They assessed 27 potential indications for ALLR/LEAP, ranking their relevance and importance. In Round 3, 73 items on biomechanics, surgical techniques, contraindications, and complications were presented for final voting. Results: Unanimous consensus supports LEAP or ALLR for high‐grade pivot shifts and revision ACL surgery. Very strong consensus confirms LEAP resists internal tibial rotation, reduces ACL stress with ACLR, and requires femoral fixation posterior and proximal to the lateral epicondyle. Strong consensus supports additional surgery for hyperlaxity and high‐risk athletes in pivoting sports. Consensus highlights risks of overconstraint, altered knee mechanics, and technical challenges. Young athletes are suitable candidates. Disagreement remains on routine LEAP/ALLR for all ACL patients, regardless of activity or compliance. Conclusions: This Delphi Expert Consensus has established that high‐grade pivot shift, revision surgery, and participation in high‐risk athletes in pivoting sports are indications for anterolateral augmentation procedures in ACLR. Generalized joint hyperlaxity and young age were identified as relative indications. The routine use of LEAP or ALLR in all ACL‐deficient or low‐demand patients is not recommended. LEAP primarily functions to resist internal tibial rotation and can reduce graft strain when performed in conjunction with ACLR. However, LEAP may overconstrain internal knee rotation and is considered a nonanatomic approach to rotational stability. For optimal biomechanical function, the femoral tunnel or fixation point for LEAP should be placed posterior and proximal to the lateral femoral epicondyle. Level of Evidence: Level V, expert opinion.

Background: Previous studies have shown that arthroscopic Bankart repair (ABR) for the treatment of anterior shoulder instability (ASI) may lead to high rates of instability recurrence and revision surgery at 10-year follow-up, but data on 20-year postoperative outcomes are scarce. Purpose/Hypothesis: The purpose was to evaluate the clinical and functional outcomes after ABR for the treatment of ASI at long-term follow-up. It was hypothesized that ABR would be associated with high rates of revision surgery, reinstability, and redislocation, but good to excellent shoulder function. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent ABR for the treatment of ASI at least 20 years ago and had initially been followed up after a minimum 10 years postoperatively were eligible to participate. Rates of revision surgery, subjective reinstability, and redislocations were evaluated, as were patient-reported outcome measures, including the American Shoulder and Elbow Surgeons score and Constant-Murley score. Results: In total, 82 patients were followed up at a median 23.0 years (IQR, 23.0-25.0) postoperatively. Twenty-eight patients (34.1%) had any kind of instability recurrence: 13 (15.9%) had reinstability at follow-up, 9 (11.0%) reported redislocations postoperatively, and 6 patients (7.3%) had both. Of those patients, 12 (42.9%) did not report instability at the previous minimum 10-year follow-up. Six patients who experienced redislocations underwent further surgery. Ten more patients underwent revision surgery for reasons other than redislocation. All patients who underwent revision surgery (n = 16; 19.5%) were excluded from further analysis. In patients who did not undergo revision surgery, shoulder function was good to excellent (median [IQR]; American Shoulder and Elbow Surgeons score, 95.0 [88.5-100]; Constant-Murley score, 87.5 [76.8-95.0]). Inferior glenohumeral laxity was associated with subjective reinstability (odds ratio, 7.214 [95% CI, 1.266-41.096]; P = .026). The use of fewer suture anchors for ABR was associated with redislocations (median [IQR]; no redislocation, 3.0 [3.0-4.0]; redislocation, 3.0 [2.0-3.0]; P = .016). Conclusion: About 1 in 3 patients reported instability recurrence or redislocations, and 1 in 5 underwent further surgery. In patients who did not undergo further surgery, good to excellent shoulder function as well as low pain and instability levels were observed at a minimum 20 years after ABR. The presence of inferior glenohumeral laxity was associated with a higher risk for subjective reinstability, and the use of fewer anchors was associated with redislocations.

Purpose: The main goal was to perform a modified Delphi process with the Ligament Injuries Committee of the German Knee Society (DKG) to structure and optimize the management of isolated posterior cruciate ligament (PCL) injuries. Methods: A structured modified Delphi approach was used to develop an expert statement. Steering group formulated an initial questionnaire and distributed it to 15 experienced knee surgeons (male/female 13/2, mean age 45 ± 5 years) of the working group in Round 1. Thirty‐one statements covering five thematic topics were then derived from the responses and comprehensive literature search (Medline, Scopus and Cochrane) using variations of different search terms (literature group). The statements underwent two rating cycles by the working group, using a 5‐point Likert scale in Round 2 and as a binary ‘agree/disagree’ in the final third round. Levels of evidence were assigned to each statement using standardized A–E and GRADE grading systems based on the available data. Results: High agreement (≥80%) was achieved for 24 of the 31 statements (range, 83%–100%), whereas for 7 agreement was <80% (range 63%–74%). The highest levels of agreement were reached for imaging modalities, treatment of PCL tibial avulsions, and preservation of native PCL fibres in reconstruction techniques, whereas the greatest divergence was observed regarding the role of leg axis and slope analyses and indications for corrective osteotomies, use of augmentation in reconstruction and post‐operative rehabilitation protocols. The available level of evidence across studies in the literature was predominantly low to moderate. Of the 31 statements, 17 were graded as expert opinion (E, GRADE: very low), 12 as case series (C; GRADE: low), and only 2 achieved higher levels of evidence (B2, GRADE: moderate). Conclusion: By providing structured treatment protocols, this Delphi‐based structured expert statement can support clinicians in day‐to‐day decision‐making and ultimately improve patient care and outcomes. Study Design: Expert survey. Level of Evidence: Level V.

Background: Although short- to mid-term clinical data of patients undergoing arthroscopic capsulolabral revision repair (ACRR) for recurrent anterior shoulder instability are promising, evidence pertaining to long-term functional, sports- and work-related outcomes is scarce. Purpose/Hypothesis: The purpose was to provide prospectively collected long-term functional outcomes, sports activity, and work ability of patients undergoing ACRR for recurrent anterior shoulder instability. It was hypothesized that patients would maintain significant functional improvement, along with sufficient sports activity and work ability, at a minimum follow-up of 20 years. Study Design: Case Series; Level of Evidence 4. Methods: Patients who underwent ACRR between September 1998 and August 2003 and had a minimum follow-up of 20 years were analyzed. Functional outcome measures included the Rowe and Constant-Murley (CM) scores, as well as the visual analog scale (VAS) for pain, which were collected preoperatively, at short-term follow-up (a minimum of 2 years), and at a minimum final follow-up of 20 years. The Single Assessment Numeric Evaluation and Simple Shoulder Test (SST) scores were only collected at the final follow-up. Return to sports and work—including sports and work level and discipline—were evaluated using a custom sports and work ability assessment tool. Results: A total of 29 patients (mean age at surgery, 28.6 ± 9.8 years) were included in the study, with a mean follow-up of 21.1 ± 1.5 years (range, 20-24 years). The rate of recurrent instability was 27.6% (n = 8), while 10.3% (n = 3) underwent revision surgery. In those without recurrent instability, the Rowe and CM scores showed significant improvements at both the minimum 2-year and minimum 20-year follow-ups, compared with preoperatively ( P < .001, respectively). Neither the CM (87.9 ± 8 vs 83.4 ± 11; P = .055) nor the Rowe (86.7 ± 18.7 vs 86.9 ± 15.8; P = .958) score differed significantly between the minimum 2-year and 20-year follow-ups. At the minimum 20-year follow-up, the VAS pain score was 0.6 ± 1.6 at rest, was 1.1 ± 1.4 during exercise, and the SST (%) was 89.3 ± 13.5. The amount of activity ( P = .022) and the subjective shoulder mobility ( P = .021) significantly declined from the minimum 2-year to the 20-year follow-up. Conclusion: Patients undergoing ACRR for recurrent anterior shoulder instability had a recurrent instability rate of 27.6% at a minimum 20-year follow-up. Those patients without recurrence maintained significant improvements in functional outcomes and achieved a favorable postoperative sport activity and work ability.